Taking Care

Do I have to get health insurance?

The Affordable Care Act (ACA), often called “ObamaCare,” requires most people to have health insurance, provides new opportunities to secure coverage, and often subsidizes the plan costs. Health care is currently a political football, with some in Congress seeking to replace it with inferior plans. For now, it is the law and the ACA rules remain in effect. General information about the ACA is available on Consumers for Affordable Health Care (CAHC) website at www.mainecahc.org/affordable-care-act-advancing-health-care-lgbtq-americans.

CAHC is a Maine-based organization that regularly posts up-to-date information about health insurance issues at the state and national levels. All of their HelpLine staff are certified as LGBTQ competent. They run a toll-free HelpLine that you can call with any questions about getting, keeping, using, or fixing problems with health insurance (such as helping you appeal if your insurance company denies a service). You can call the HelpLine at 1-800-965-7476 or visit their website at www.mainecahc.org.

Under current law (which could change), most people are now required to have some basic health coverage because of the ACA. Insurance normally comes through:

your parents (if under age 26); your college or an employer;

the Health Insurance Marketplace (directly set up by the ACA);

direct sales from private insurers; or

government programs like Medicare (for older persons and people with disabilities) and Medicaid, also called MaineCare, (e.g. for income eligible families, young adults, seniors, and people with disabilities).

How do I get health insurance and will transition related care be covered?

Let’s break down how you can get health insurance from each of the five sources listed on the previous page:

1) Important ACA Rules Allow Coverage Under Parent’s Plan Until Age 26

Under the ACA, young adults may remain on or be added to their parents’ coverage until the age of 26. So if a parent has an existing plan – whether through a job or the Marketplace – that provides transition-related care, then you could qualify for some types of care depending on your age and the terms of the plan.

If you aged out of the foster care system in Maine and are under 26 years old, then you are eligible for free MaineCare coverage no matter what your income is.

As discussed below, young people have many options to obtain health insurance separately from parents’ plans. If you’re not sure which option is right for you, find a local navigator or enrollment assister or call the CAHC HelpLine at 1-800-965-7476.

2) Insurance Through Your Own Employer

If you are working, you may have insurance through your job. Look at the “Evidence of Coverage” or “Certificate of Coverage” or “Contract of Insurance” to understand what is and is not covered. If there are exclusions in the coverage, you may file a complaint about a blanket exclusion on all transgender-related care (under ACA Section 1557) directly in court. Please contact GLAD or another knowledgeable attorney as soon as possible!

3) The Insurance Marketplace of the ACA

If you don’t have health care coverage you can buy a plan with private companies through the Health Insurance Marketplace, also called healthcare.gov.

You can find additional information and resources about Maine’s Marketplace at:

Apply in-person with the help of a local health insurance navigator or enrollment assister. To find a navigator or assister near you, visit https://localhelp.healthcare.gov/, or call CAHC at 1-800-965-7476.

Apply over the phone by calling the Marketplace directly at 1-800-318-2596.

If the ACA is still in effect, open enrollment on the Marketplace will start on November 1, 2017 and continue through December 15, 2017. You might be able to sign up other times of the year if you’ve had a change in circumstances – for example, if you’ve lost other insurance. This is called a “special enrollment period”. You can obtain private insurance for yourself, as a couple or as a family through the three companies that work within the Marketplace: Anthem, Community Health Options (CHO), and Harvard Pilgrim HMO.

In the past, Anthem and Harvard Pilgrim’s Marketplace plans had blanket exclusions on transition related care, and Community Health Options only covered hormones. For 2017, however, all of the insurers that sell plans on Maine’s individual market (meaning coverage you buy for yourself) have removed those exclusions.

When you buy a plan through the Marketplace, depending on your income, you may be eligible for tax credits and subsidies that lower your monthly premiums and out-of-pocket costs. Almost 9 out of every 10 Mainers buying coverage through the Marketplace qualify for discounts.

BEWARE: These discounts are not available if you buy a catastrophic plan, which is a type of plan that offers very little coverage. These plans are an option only if you are under 30, or if you qualify for a “hardship exemption” from purchasing other types of insurance.

4) Private Insurer Plans Sold Outside the Marketplace

Discounts available to health insurance policies purchased through the federal Marketplace are not available when you buy an insurance policy outside the Marketplace – even from the same company.

Any health policy sold on or off of the Marketplace must cover “essential health benefits,” including preventive care, and may not discriminate based on a pre-existing condition like gender dysphoria. In addition, if, for example, an individual who identifies as male has ovarian cancer, the insurer cannot deny coverage.

According to Consumers for Affordable Health Care, Aetna has no explicit exclusion but only sells policies in some counties in Maine. Maine’s other three individual market insurers – Anthem, Harvard Pilgrim, and Community Health Options – sell plans statewide and also do not have exclusions on transition related care. However, all of these companies follow the same open enrollment periods as the Marketplace, so even if you are buying a plan directly from the company you’ll still have to enroll between November 1st and December 15th or have a change in circumstances that allows you to sign up at other times of the year (this is called a “special enrollment period”).

5) MaineCare

Depending on your income, you may qualify for Medicaid, also called MaineCare here in Maine. There are several ways to apply for MaineCare:

DHHS has 45 days to determine if you’re eligible for MaineCare after you apply. DHHS sometimes makes mistakes, so if your application is denied, or if you don’t hear back within 45 days, call CAHC to find out what you should qualify for. You can also call DHHS directly to ask for a Fair Hearing. CAHC has resources available on Maine Care at www.mainecahc.org/guide-to-maine-healthcare/resources/ and can be reached at 1-800-965-7476.

In practice though not in law, the State of Maine excludes transition-related care. The good news is that it has also covered hormones when the underlying diagnosis of gender dysphoria is made by a qualified physician. As a practical matter, this creates uncertainty. If you have an issue, you should contact CAHC, and CAHC may refer you to GLAD for legal assistance.

What plans cover transition related care?

You must look at the terms of your plan. The same company may have different terms depending on whether the plan is from an employer or whether you bought it yourself from the insurance company or on the Marketplace. However, all individual policies that you buy on the Marketplace or directly from an insurance company cover transition related care in 2017. We do not know if the rules will change as we move into 2018 and beyond.

In addition to contractual exclusions included in the terms of a plan, insurance companies also use medical guidelines or clinical standards of care that describe what care is covered under what circumstances. Some care you believe should be covered may be deemed “cosmetic” rather than medically necessary by your plan if you don’t meet their guidelines.

So, even if a plan doesn’t explicitly exclude transition related care, this doesn’t mean all services are covered for all people. For example, Aetna, Anthem, and Harvard Pilgrim’s individual plans all use medical guidelines for transition related surgeries that require a person:

to be at least 18 years old;

to have a gender dysphoria diagnosis; and

to have letters of support from qualified health and mental health professionals.

In addition, Anthem and Aetna usually require 12 months of hormone therapy for most surgical procedures, and sometimes also require 12 months of “living in a gender role congruent with their gender identity” or “of successful, continuous full time real-life experience in their new gender.”

You can find the full guidelines summarized above at the links below (current as of 5/3/17). These guidelines are updated periodically, so contact your insurance company directly for the most recent guidelines used by your plan. Medical guidelines can be confusing, so ask your doctor or an advocate if you need help. You should also check your plan’s coverage documents to find out what is covered or excluded under the terms of your plan.

For people under 18

Even if you’re under 18, your plan may still cover hormone therapy. Aetna, Anthem, and Harvard Pilgrim all cover hormones for people under 18 years old when their guidelines for those treatments are met. Ask your insurance company for the medical guidelines used by your plan to find out when hormone therapy is covered.

Please call CAHC or GLAD if you are concerned about meeting the terms of the plan or are denied coverage for a medically necessary procedure because you do not have sufficient documentation or do not meet the durational requirements. If you have trouble getting a copy of the medical guidelines used by your plan, call CAHC or the Maine Bureau of Insurance at 1-800-300-5000 for help.

Can I appeal unfair treatment or discrimination by my insurance?

In many instances, yes! In many instances, you shouldn’t take “No” for a final answer! If you are denied necessary care or face an improper exclusion, you have rights of appeal, and may also have a discrimination claim that can be filed in court on your behalf by a qualified attorney. As with any denials of coverage, be sure to review your plan and follow any prescribed deadlines for appeals of or challenges to denials.

In addition, attorneys may file a claim for discrimination in court. Challenging discrimination in court is an enormous undertaking. You can call GLAD to request help with the process, including deciding whether it’s the right course of action for you. GLAD’s legal help line, GLAD Answers, is available online and at 800-455-4523.

The regulations interpreting the ACA, including the non-discrimination regulations, remain in effect except for those on gender identity and contraception.

Denying coverage based on gender identity still states a claim for sex discrimination that can be brought in court. HHS regulations stated that a ban on transition-related care is forbidden, and that may also be influential information to a court.

If your coverage is through an insurance policy issued by an employer, Maine’s employment discrimination laws may also provide recourse.

Consult an attorney if you face these barriers. GLAD Answers is a good place to start. In order to ensure your ability to challenge exclusions, it is important to read your insurance contract and meet any deadlines for taking an appeal from a denial of coverage for medically necessary care.

Can a minor start a medical transition (hormone blockers) with the consent of only one parent?

Generally speaking, parents have the legal custody and control of their children and that extends to medical care and decisions around medical treatment.

If the parents are currently married

Yes, one of the parents can authorize medical transition. However, if the other parent disagrees strongly, good counseling or mediation are advisable to avoid unnecessary contention or a separation.

If the parents were married and later separated

If the parents were married and later separated, then there is a court order about “parental rights and responsibilities.” If the court orders say that the parent supportive of medical transition has sole decision-making authority for medical care, then yes, consent of one parent is enough. But if they have shared decision making for medical decisions and cannot agree, the matter could go back to court for determination by a judge about whether medical transition is in the youth’s best interests.

If the parents are divorced or were never married

Courts issue orders about parental rights and responsibilities when unmarried persons make claims for paternity or parentage. If the court orders say that the parent supportive of medical transition has sole decision-making authority for medical care, then yes, consent of one parent is enough. But if the parents have shared decision making for medical decisions and cannot agree, the matter could go back to court for determination by a judge about whether medical transition is in the youth’s best interests.

In addition, a parent opposing medical transition could go to court and try to modify the court orders about which parent has responsibility for decisions about medical care. For example, the opposing parent could seek joint or sole medical decision making, either of which could prevent the requested medical care. The opposing parent may also request additional parental rights and responsibilities, such as taking over decisions about where the child lives or attends school. These cases require good legal representation. Feel free to contact GLAD, Pine Tree Legal, and others for assistance or referrals.

What can I do if my parent or parents are not being supportive of me?

In a perfect world, parents would be immediately accepting of their LGBTQ children, but familial journey to acceptance is often that – a journey. It might be helpful to provide your parents with some of the following resources designed to assist families with recently “out” children. Here are some of the many resources available:

Amy Ellis Nutt, Becoming Nicole: The Transformation of an American Family (a book about a Maine family)

Derry & Nicole Rundlett, Full Circle: A Father’s Journey With a Transgender Child (a book about a Maine family)

What can I do if my parent or parents are actively opposing my sexual or gender identity, including trying to change me?

It’s important to remember that your sexual orientation or gender identity are not parts of you that anyone should ever try to change. You are wonderful the way you are, even if you’re currently being met with opposition.

Seek support! Many of the organizations supporting this guide can help you directly, and others can help you indirectly with information and referrals.

Because we live in a society that perpetuates myths and stereotypes about LGBTQ people, your parents likely believe that their efforts to change you are coming from a place of love. Most are shocked to learn that saying things like “this is a phase” or “you’re too young to know,” denying access to friends, and pretending you are not who you are can be harmful behaviors that can lead to depression, anxiety, and self-destructive behavior. Enlist siblings, other relatives, and supportive adults who can help educate your parents or caregivers with the resources listed in this guide.

As discussed below, there are also limited legal steps available when a situation is destructive or intolerable.

What is “emancipation” and how can I use it?

The emancipation process makes the youth into an adult for many legal purposes, such as being able to sign a rental contract for an apartment, hire a lawyer, and obtain medical care.

A youth who is 16 years of age or older, and who refuses to live with a parent or guardian, may file a petition in the District Court where the parents or guardian live. To prevail, they must prove:

they possess adequate maturity for decision making;

have a plan to take care of their basic needs, e.g. where they will live, how they will support themselves, their educational plans; (note: there is no parental child support if the petition is granted)

it is in their best interests for the emancipation to be granted.

The youth will be appointed an attorney for the proceeding. As with guardianship, the petition may be uncontested or the parents may contest.

One of the biggest difficulties with emancipation involves proof that the youth can care for themselves. And given the amount of discrimination against transgender youth in particular, this presents a real bind.

Kids Legal (part of Pine Tree Legal Assistance) has good information online explaining emancipation and describing the process for filing for emancipation at: www.kidslegal.org/emancipation-maine. Kids Legal is also currently working to add more materials that speak directly to the needs of LGBTQ youth.

What do I do if I’m not old enough to be emancipated, but I am feeling awful because of how my parent or parents are treating me? Can a supportive relative become my guardian instead of my parent or parents?

A youth may file a petition for guardianship on their own in the county probate court where they live or are present. Someone else (like the relative) may file to obtain guardianship over a youth as well. Another individual can also file a petition seeking guardianship, either temporarily, or permanently (until age 18). Pine Tree Legal (our statewide legal services office) has good written materials online describing the process and alternatives: http://ptla.org/library/449.

Sometimes guardianship proceedings are uncontested and things can move more quickly. But when the parent(s) fight the guardianship request, the person petitioning for guardianship must basically prove parental unfitness. There are many parent behaviors and family situations that are far from ideal, but the courts will likely not allow the petition unless the parent(s) is causing trauma and harm to their child. Some trauma and harm is obvious – like bruises and sexual abuse – but an LGBTQ youth who is not physically beaten or sexually assaulted can expect to have to prove trauma and harm when it comes to rejecting behaviors by the parent(s). It is probably obvious, but it is not abuse and neglect to not like your parent(s) or to think you could have more freedom somewhere else.

Youth 14 and older have some voice in the proceedings in that they are asked to indicate their consent to a guardianship. Depending on the circumstances, the youth may also file in court a sworn statement (declaration) about harm caused by the parent(s).

A guardian can enroll the youth in school and make medical decisions, and generally provides for the child’s welfare. However, legally (if not always practically), the parent(s) remain financially responsible for the child.

Most county courts have the necessary guardianship forms online and the court “register” – a clerk – may assist those who come into court for help. For Guardianship forms, see:

Advocates are working to expand options for sheltering youth in the rest of the State.

Even if you do not reside near one of the 3 youth serving shelters, everyone, of any sexual orientation, gender identity, or gender expression, has the right to access shelter services free of discrimination and harassment. For transgender people in particular, you have the right to access shelter restrooms, showers, dormitories, and other facilities consistent with your gender identity; to be referred to by names and pronouns consistent with your gender identity; and to express yourself by wearing gender affirming clothing.

Some youth who are 14 and over who have no home, or leave their homes, or leave foster homes, may have difficulty accessing services from the State Department of Health and Human Services. Please contact an attorney if this happens to you. This leaves youth with the option of shelter, guardianship with a willing adult, or, if the youth is 16, they may be able to be legally emancipated from the parents. (In Maine, youth are considered adults at age 18.) Advocates are examining how to create more shelter and housing options.

For those who want to offer a bed to youth, Maine has no specific legal prohibition on “harboring” runaways.

For youth under 14 who do not want their parents to know where they are, they must make that request in writing and that will keep them at the shelter for three days. Also, if the youth is in danger of being hurt, the shelter will not call the parents but will contact the Maine Department of Health and Human Services (DHHS).

It is not illegal to run away, and a child cannot be arrested, fingerprinted or put in jail for running away. Local police can take youth into “interim care” for up to 6 hours, but this is not an arrest. If the youth is in a safe place, the police may decide not to take the youth into interim care while they work something out with their family. Once in interim care, the police must call the parent(s) and can ask them to take the child home only if the parents and youth agree. If there is no agreement, they will take the youth to DHHS.

Whether it is a shelter, the police, or the youth themselves that contact DHHS, the agency has several options. If DHHS believes the child would be harmed at home, or the youth does not agree to return home, DHHS may obtain temporary custody and place the child with another parent, relative, or a foster parent.

Additionally, many organizations – including GLAD and many of the organizations co-sponsoring this guide – work directly with youth. There are resources all over the State so you can find someone to talk to! You can reach out to:

How do I change my name in Probate Court?

The Maine Law Court, our highest court, has already ruled that a judge should grant a name change as long as the petition is not submitted for any fraudulent reasons and the change of name does not interfere with the rights of others. In re. A.M.B., 2010 ME 54, P4 (2010). Being transgender in itself is certainly not cause for concern.

In order to change your name, your legal custodian will need to file a petition on your behalf in the Probate Court in the county where you live. An emancipated minor and youth 18 years old or older may proceed on their own without a legal custodian.

You will need to complete and file form CN-2, a petition for a name change for a minor (available at http://ptla.org/sites/default/files/CN-2.pdf). As the form explains, you will need to include a certified, up-to-date copy of your birth certificate. When you file the petition (along with your birth certificate and other necessary documentation), you will be charged a $40 filing fee. (You may also need a certified, up-to-date copy of a divorce judgement, court order pertaining to custody, and/or certified death certificate of a deceased custodian, if these apply to you.)

Cases must be filed in District Court rather than Probate Court in some circumstances. If there are ongoing proceedings about your custody or parental rights of you or your children in the District Court, the petition must be filed in the District Court.

Either way, the judge typically requires public notice of a proposed name change – in writing through newspapers – so that people can object if they are concerned you are changing your name to commit fraud or to avoid responsibilities like debt repayment. You or your lawyer can request permission NOT to publish your name change request – called a motion to waive notice by publication – if you have good reasons. Maine law also specifically allows someone who is an “abuse victim” to request waiver of notice. Title 18-A Maine Revised Statutes section 1-701 (b), (c).

You may ask the judge to waive the publication requirement when necessary to protect your safety. If you are making a safety claim, you and/or your legal custodian will need to show that you are a victim of abuse and that you are currently in reasonable fear of your safety. The Court (Judge) makes the decision about whether to let go of the notice requirement in your case.

Because of concerns about fraud or avoiding responsibilities, the judge may require you to undergo one or more of the following background checks: a criminal history record check; a motor vehicle record check; or a credit check. You may be required to pay the cost of each background check that is required.

Once the petition is granted, the judge will also make and preserve a record of the name change.

You or your lawyer may request that your records be sealed. The advantage of sealing is that it makes your records unavailable to the public.